We are gathered here today to dedicate a splendid new edifice to the service of elderly New Yorkers. Like its sister structures here at Kingsbridge Center and at the Manhattan headquarters of The Jewish Home and Hospital for Aged, the Salzman Pavilion presents exciting proof of what can be done toward meeting the needs of at least some of the aged through vigorous government action combined with foresighted private philanthropy. The State of New York, The Jewish Home and Hospital, and Mr. Mortimer Salzman are all to be commended and congratulated for their enterprise and compassion.
The comprehensive, multi-level care provided for residents of this institution is exemplary. Regrettably, however, no such care is available for large and growing numbers of aged Americans.
Let me cite one case in point. An 83-year-old woman was living alone in her small apartment in Baltimore. She had neither relatives nor friends. Her only source of income, Social Security, was adequate, at one time, to cover her basic needs -- food and rent -- but that was before inflation came along. When it did, all that she was able to do was pay her rent and spend pennies rather than dollars for food. One day she was found unconscious on the floor of her apartment and was taken to a hospital. The diagnosis? “Mental derangement.” Presumably recovered, thanks no doubt to decent food and treatment, the frail old woman was sent home -- alone.
But soon she had to move, because her apartment building was converted into a condominium. After being turned away by a number of building managers who felt entitled not to rent to elderly persons, she paid a private service-agency to help her relocate. The agency found her a third-floor, single-room walk-up. She took it -- and her physical and mental health worsened. After being found unconscious on three different occasions, she was finally admitted to a hospital for observation and treatment.
But who was to assume the financial responsibility? The service-agency, the hospital, and the local government each refused to shoulder the burden. Eventually, the woman was placed in a private home by a government service program -- a program which now has ceased to exist.
Who is to blame in situations like this -- the landlord, the doctor, the service agency, the hospital, or the Government? To some extent, all of them, perhaps. But a major share of blame falls upon the rest of us, I believe. Because it is we who have failed and are failing the aged -- all of us who make up a society that seems afraid to come to terms with aging as a natural, inevitable life process – afraid to recognize the claim on our common humanity of the millions of our fellow-Americans who, because they are old and enfeebled, are denied the respect, the dignity, and the choice of living arrangements to which they are entitled by right.
The consequence of this kind of thinking is that far too many older Americans are stereotyped as “over the hill” and shunted aside. Despite the increase in Social Security benefits, in anti-discrimination legislation, in Medicare and a whole battery of government programs, older Americans are discriminated against, neglected, and even victimized. Tomorrow -- unless we act today -- it may be our turn. For tomorrow we will be “older Americans.”
It is sad but it is true that in this Bicentennial Year, the pursuit of happiness has become a struggle for survival for millions of our fellow-citizens over the age of 65. One-third of the nation’s 20-million elderly men and women live in poverty, four-and one-half million of them fighting to exist on less than $2,000 a year. One third of the elderly -- and that means over six million people -- are beset by chronic illness. Nearly 12 percent of the elderly live in housing officially classified as substandard -- and for aged blacks, that percentage is almost twice as high. Additional millions are trapped in generational ghettos. For two-and-a-half million elderly, this “entrapment” is an actual fact, because they are restricted to their homes by their physical weakness, and are able to get around at all only with mechanical aids.
What are we as a society doing to ameliorate these conditions? Far too little. As a matter of fact, President Ford in his budget message proposed measures that are almost certain to worsen the plight of the aged. To be sure, the Ford proposals regarding Medicare would benefit some three millions of the elderly and disabled, but all beneficiaries would have to pay more. The annual medical deductible, for example, would rise from the present $60 level to $77. At the same time, beneficiaries would be required to pay ten percent of their hospital bills, or up to $500 a year for hospital care.
President Ford also seeks substantial cuts in expenditures for social services of direct benefit to the elderly. The total Ford package adds up to one billion, seven-hundred million dollars less for health security -- meaning that the President’s proposed economies would cost every Medicare beneficiary an average of $85 a year. His budget, however, would do nothing to bring down the steadily mounting cost of health care.
Can a practical alternative course be charted for America’s elderly? I for one think that such a course not only can but must be set in the immediate future.
Continuing on our present course makes no sense in terms of economics on the one hand or humanity on the other. We cannot go on spending more for health services which continue to cost more and which provide the least help to those we want to help most -- the aged. We have got to call a halt to policies which force Americans out of employment because they are regarded as “too old,” regardless of their ability to contribute productively. Government action which now virtually dictates institutional care must be ended in favor of action that will encourage non-institutional care in the community for those elderly citizens who are physically and psychologically able to live productive lives.
Most important of all, I submit that we must adopt a new national strategy for the aged. In all that we do, our objective must be to assure that older Americans are granted the dignity of choice: the choice of living alone or with their families... in the cities or in rural areas... in the community or in competent care-institutions... and of working or otherwise contributing to society. The choice must be theirs -- not yours, not mine, and not the government’s. The need for feelings of self-worth and for personal fulfillment does not vanish into thin air at age 65. Meeting that need is not an act of charity or even compassion. It is a recognition of the human ccndition. It is a long-overdue implementation of the American dream.
The new national strategy for the aged that I propose begins, as I believe it must, with assuring their economic security. In our society, an adequate income is the precondition of effective choice. For the elderly, that means insuring Social Security benefits against inflation by indexing and maintaining the financial integrity of the Social security system. But it also means re-examining employment policies so that millions of Americans over 65 are not arbitrarily denied the opportunity to work.
Some 12 weeks ago, I announced a comprehensive six- point program aimed at reducing inflation and unemployment -- reducing them sharply. Economic developments in the interim have only served to validate that program further. Inflation, which hits the elderly hardest of all, would be attacked directly in six different, but Closely coordinated ways.
First, we could check food-price inflation through maximizing domestic production while assuring realistic price Supports for farmers and creating national grain reserves. Second, we could check energy-price inflation through a tough program of conservation ... through increasing domestic production without inflationary increases by establishing a price ceiling for domestic oil, indexed to production costs ... and through investing now in an energy future based on renewable resources. The third way we could check inflation is by regulating wages, prices, and profits through guideposts and “jawboning” on a permanent basis, with authority to institute sector-by-sector controls if necessary.
The fourth way to check inflation is by reforming anti-trust laws to put the burden of proof on the energy giants and on other leading companies in concentrated markets to justify their power in terms of the public interest. The fifth way is to increase competition by using investment tax credits and other investment incentives to help break production bottlenecks. And the sixth way to check inflation is by stabilizing the value of the dollar worldwide through a global monetary system that would reduce reliance on the United States dollar as a reserve currency in international finance.
Fighting inflation has particular relevance for the tens of millions of Americans for whom Social Security benefits represent the principal if not their only source of income. In recent years, some progress has been made toward protecting benefit levels against inflation by indexing them to the cost of living. That represents simple economic justice for older Americans. Fortunately, this year President Ford has not repeated his proposal to set a cap, below the inflation rate, on the adjustment of benefits. Rather than making retired Americans bear the burden of fighting inflation, we need some policy -- other than the Ford policy of forced unemployment -- to control the forces that push up prices.
Adequate benefit levels indexed against inflation -- coupled with effective policies to control inflation -- must be our first commitment to older Americans. But to maintain those levels, it is urgent that we take steps to maintain the financial integrity of the Social Security system. That will mean increased payments to the Social Security trust funds. But those payments need not, and indeed should not be financed, as Mr. Ford proposes, by increasing the regressive payroll tax. Rather than going about it the Ford way -- which is to force 85 per cent of those covered by Social Security to pay more -- we should raise the income base that is subject to the Social Security tax, so that those who have more pay more, and those who pay more get more.
In other words, we must reduce the burden of the regressive payroll taxes which finance the Social Security System. Those taxes now account for more than one-quarter of total federal revenue. Because of the flat rate, which applies only to the first $15,300 of earned income -- a figure that will rise to $16,500 in 1977 -- every dollar earned above that level goes untaxed for Social Security purposes. That means that high-income individuals pay only a tiny fraction of their income in payroll taxes, while low- and middle-income earners bear the full rate. Economic democracy demands that this regressive payroll tax be made progressive.
As I have said, an adequate income is a precondition of effective choice in our society. Arbitrary dismissal from employment solely because of age flatly negates that choice. Yet existing federal legislation protects only those who are under 65 from job discrimination on the ground of age. Corporate policies mandating retirement below age 65 are not considered to violate this legislation. Such mandatory retirement is becoming increasingly widespread, even though reputable polls show that seven out of every ten Americans oppose this concept.
Such opposition is solidly based in logic. To me, it seems like elementary common sense not to discourage but to encourage those who have the capacity, the desire, and the need to continue as wage-earning members of society. Certainly, those who have worked throughout their lives should have the opportunity to retire if they so desire or if they are disabled. But it is high time that we reexamine, and reverse, a policy which not only compels people who want to support themselves to leave the work force at age 65 or younger, but which also shifts the financial burden for their support to the middle generations.
It seems to me, further, that it is the proper responsibility of government to foster programs which would provide opportunities for part-time employment of workers over the ‘age of 65. The Federal Government and the Department of Labor in particular should work with industry and unions in exploring options for part-time employment and flexible working schedules, and in disseminating information nationwide on the growing number of available part-time and flexible- schedule jobs. These programs could help significantly to increase the nation’s work force and to alleviate a financial burden, while providing millions of involuntarily retired Americans with the dignity and the life-enriching benefits of self-support.
The second component of the national strategy for the aged which I propose concerns health care. While inflation and job discrimination have robbed older Americans on limited incomes of the resources needed to shape their futures, the soaring costs of health care have left them with an unaffordable choice: debilitating medical expenses or debilitating ill health.
The one-hundred-and-eighteen-billion-dollar healthcare industry is plagued both by gross inefficiencies and gross inequities. Every day, over 100,000 hospital beds lie empty at a cost of two-billion dollars a year. At the same time, however, the poor, the elderly, and people living in rural areas have little access to quality health care -- and fewer resources to cover the costs.
The elderly require more frequent access to quality medical care than do other groups within the population, and they also require a greater measure of ongoing preventive and diagnostic treatment. Older Americans have one chance in six of being hospitalized in any one year. The economic adversities to which we all have been subject in recent years have taken a heavy toll of the health of the elderly because so many have been forced to downgrade their diets and to use less fuel. And they have been hit particularly hard by rising medical costs: each Medicare participant now must pay approximately double what was required when the program went into effect. And it’s getting worse: the health-care inflation rate stands today -- I should say, surges forward -- at 15 percent per year. The average amount of out-of-pocket health-care expenses paid by each person over 65 is $550 yearly -- a full $250 more than the expenses paid for by the average citizen under 65. In 1970, elderly families paid 7.6 per cent of their income for medical care -- twice the percentage paid by younger families above the near-poverty level.
A recent poll by Pat Caddell showed that most Americans are willing to support increased taxes only for health care. But increased federal spending on today’s overloaded, inefficient system will increase costs more than it will improve services. What is required is a phased replacement of the uncontrolled, unmonitored system of the past with a more cost-effective approach. Yes, that means a comprehensive national program of universal and prepaid health insurance. Yes, too, to the fact that such a program will be costly. But make no mistake about it: the costs of continuing the present system would be greater still.
Comprehensive national health insurance would, of course, replace Medicare and Medicaid. Meantime, however, priority attention must be given to reforming today’s system for delivering health care to the elderly. The reforms I have in mind include five above all.
The first reform would be to require that those physicians who participate in the program accept Medicare payments, at a reasonable level of compensation, as payment in full for the service performed. Only in this way can we begin to hold down the costs of medical care for the elderly.
The second reform would be to place a ceiling of $250 on out-of-pocket patient costs for hospital treatment, and a ceiling in that same amount for outpatient doctor’s fees, with the balance to be covered by Medicare. We should consider reducing these ceilings further for the lower-income elderly.
The third reform would be to reduce gradually or to eliminate all patient fees under Medicare, including deductibles and co-insurance. We should seek to eliminate the monthly premium which has kept one million elderly persons from joining -- most of them members of low-income or minority groups. Attention should also be given to extending Medicare coverage to include drugs prescribed on an outpatient basis... dental care... and necessary medical items such as dentures, hearing aids, and eyeglasses.
The fourth reform in today’s system of delivering health care for the elderly would be to modify current utilization-review procedures -- so that Medicare and Medicaid patients in non-profit facilities would not be ousted merely because they no longer require full-time nursing care. They will, however, continue to require some measure of medical attention. In the long run, therefore, it will prove far less costly to allow them to remain in that same facility, because so doing will obviate the physical and psychological traumas to which the elderly are particularly prone.
The fifth reform would be to extend at-home health benefits under Medicare and Medicaid as an alternative to far more costly institutional care. Because the system refuses to pay for care in the home, older Americans frequently are compelled to remain in institutions merely because no viable alternatives are available to them.
These reforms will help. But equally needed to improve health care for the elderly is an increase in medical understanding and concern for the aging patient. Toward that end, I would strongly recommend that medical societies and hospital associations set up special committees to deal with complaints of discrimination against elderly patients and to hear charges of medical neglect.
I would also urge the National Institutes of Health to take the lead in promoting basic and clinical research in the causes, prevention, and cure of diseases associated with old age. Such leadership is sorely needed. Few if any hospitals provide residencies in geriatrics. Even in our medical schools, students are rarely exposed to the systematic study of the medical problems of the elderly. For that reason, it is good to know that at long last a specialized center has been created at the National Institutes of Health to deal with such problems. But that’s just the good news on this point. The bad news is that while the center has been created on paper, it doesn’t exist as a functional entity because it hasn’t yet been funded.
While we are waiting for action on that front, I would urge that consideration be given to developing outpatient clinics based at those nursing homes which possess staffs equipped with the requisite expertise. Every major hospital in the country should be encouraged to “lean on” such nursing homes toward that end. I would further recommend that hospitals and the medical profession begin to place increased emphasis on preventive medicine for the elderly, and that in this process, greater and wider use be made of non-physician health professionals
Now I should like us to consider the third major component of a new national strategy for the aged. That is family living. Now, as we all know, our society’s favorite solution to virtually every human problem seems to be to combine bureaucracy with institutionalization -- a combination that hardly ever works. I propose that we develop realistic alternatives to that so-called solution. Such a proposal is rooted in the solid fact that the majority of older Americans are able to do much more than our society recognizes. Forced into dependency by retirement laws that underestimate their continuing capacities, elderly people too often are shunted into institutions. They should be encouraged instead to make positive contributions not only to the families but also to each other.
For the elderly who live apart from their relatives, we need more alternatives like the Share-a-Home Association in Florida, where nearly two dozen older people jointly own and manage a large house. Consideration should also be given to programs like the one in Rhode Island where the elderly help themselves by donating their talents and energy to a home- maintenance program for senior Americans. Under that program last year, volunteer craftsmen winterized more than a thousand homes free of charge.
The current practice of exiling from the community of many older citizens who want to remain there increases the need for nursery and day-care facilities to provide for the children of working mothers. The “Foster Grandparents” program which I started in the Office of Economic Opportunity proved that practical alternatives to institutionalized exile do exist. That program or its equivalent must be extended as a national policy, a policy that would help to tear down the generational ghettos and restore many of the elderly to respect and usefulness.
The fourth component of a national strategy for the aged has to do with supportive services. Whether older Americans live alone, in peer communities, or with their relatives, they require a range of supporting — if they are to be truly free to choose their life-styles. Just one service, for example -- a daily home-delivered meal -- can make it possible for an older person to continue living in his or her own home.
It is a fact, however -- known only too well to those who have traveled up and down this country as I have -- that supportive services for the elderly are fragmented and they are not consistently available from community to community. In many instances, those in need simply do not know where to find services that are available. We need one-stop, community-based senior citizen service centers geared to perform three vital functions.
The first would be to centralize and coordinate a whole range of supportive services from home health-care for the house-bound elderly to counseling on their problems and their rights. In other words, much of what you are doing here through your G-O and Day Care Programs should be expanded into a national policy.
The second function of these centers would be to provide employment referral services, particularly for part-time and flexible-schedule jobs. And their third function would be to oversee the provision of all these supportive services while keeping the community fully informed about their availability.
These senior-citizen centers -- like the neighborhood service centers pioneered by the Office of Economic Opportunity -- should be directly responsible to the community they serve. They should operate through non-profit corporations or other entities controlled by the elderly or by existing private service organizations, and they should offer paid employment to elderly members of the community. Funding and professional staff should come volunteer and paid.
Now we come to the fifth component of the national strategy I am proposing for the aged -- and I should like you to know that I am deeply pleased to be here in this particular place to discuss it. For that component is the comparatively rare element in the total picture of geriatric care known as comprehensive-care facilities -- and, beyond question, The Jewish Home and Hospital for Aged is an outstanding example, perhaps the outstanding example in the nation, of such a facility.
What is particularly exciting to me about these facilities is that they offer the elderly still another option in choosing their individual life-styles. They provide a wide range of services under one management -- from hospital-level service to day care, from skilled nursing service to health-related care and residential accommodations for independent living -- and all of this along with programs of physical and mental rehabilitation, cultural recreation, and education not only for their residents but for health professionals and concerned lay people as well.
In those places where comprehensive care facilities have been established -- as in Philadelphia, Baltimore and Gaithersburg, Maryland, and here in the Greater New York area -- they have provided the answer to a multitude of interrelated problems.
These centers are equipped to provide three levels of residential care as well as out-patient services. The elderly who are acutely ill and require round-the-clock nursing are accommodated in skilled-nursing facilities. Others requiring less constant medical attention are provided with a sheltered environment with immediate access to care as needed. The physically self-reliant elderly are offered cottage or apartment housing, like your own Kittay House, which provides daily meals and housekeeping and recreational services, along with access to the Center’s medical services should occasion demand. In such centers, it is obviously easy to avoid the trauma that is all too commonly inflicted on an older person by shifting him from nursing home to hospital and back again because of deterioration or improvement in his physical condition.
The best of these facilities -- and here again let me say that I believe this Home could serve as the national model -- provide not only first-rate medical care and comfortable, pleasant housing, but also an improved quality of life. They do so through their programs of occupational therapy and intellectual stimulation... recreational activities inside the facility and out of it also... gardening activities... resident-run gift and craft shops... art shows featuring residents’ works... programs of volunteer services to the community’s schools... even political expression through resident governing councils. Indeed, each of these comprehensive-care facilities could serve as the site of one of the community-based senior-citizen service centers that I advocate, to encourage effective coordination of supportive programs for the elderly.
Many of these comprehensive-care facilities, including this one, also extend into the community with geriatric-outreach programs that provide annual physical examinations and back-up services like dentistry, ophthalmology, podiatry, and diagnostic X-ray services. Participants are also offered a day program of physical and occupational therapy, recreational activities, psychological counseling, and nutritious lunches.
Unfortunately, there are no more than a dozen of these comprehensive-care centers in the entire country today. We need many more. We now have one-million, two-hundred-thousand Americans living in 23,000 nursing homes, many of them inadequate for their patients’ needs. The costs are enormous-- between ‘seven-and-one-half and ten billion dollars a year, of which at least four-billion, two-hundred million dollars comes from federal funds.
The commercial sector -- the nursing homes operated for profit -- account for the lion’s share of these expenditures. Some of these commercial homes provide adequate service but, as investigation after investigation has made clear, many do not. It seems to me that a significant a portion of those billions of dollars could be diverted from the commercial to the non-profit sector -- to homes sponsored by church, union, community, and cooperative groups whose chief goal would be optimum care of the resident rather than optimum profits. The competition between non- profit and for- profit facilities could lead to an improvement in the quality of service offered by both. Meantime, of course, we must press for vigorous enforcement of existing standards, and insist that all nursing homes, proprietary as well as non-profit, provide only quality care.
It should be our goal to develop top-quality comprehensive-care facilities in each of our major population areas. A start could be made in that direction, first, by diverting part of the funds now going to commercial nursing homes and, second, by allocating to the construction of comprehensive-care facilities a portion of the housing funds now earmarked for the elderly. In most instances, the machinery to accomplish this goal is already in place. We need no new bureaucracies to make progress in this area. What we do need are new priorities and new objectives.
The sixth component of a new national strategy for the aged is non-institutional housing. Let’s face it, housing is a major area of discrimination against the elderly. Many apartment owners refuse to rent to older citizens. The elderly have suffered disproportionately from the cumulative effects of the conversion of rental apartments into condominiums... the freeze on new housing... and the weakening or the end of rent controls. As I have said, nearly 12 per cent of our aged citizens live in housing officially classified as sub-standard.
Decent housing is no less important to older Americans than is affordable, accessible health care. Dignity is denied and hope is destroyed by over-crowded, vermin- infested tenements in our inner cities... by suburban housing increasingly beyond the economic resources of most of our elderly... and by shelter in our rural areas that doesn’t qualify as human shelter at all. Not all of these conditions can be remedied by government policy. But each of them has been worsened by the policies of malign neglect which have depressed the housing industry and demoralized the elderly.
Our response to that neglect must be a renewed commitment and a redirected effort to solve the problem. The program I propose to help bring adequate housing to the elderly includes the following major features... first, lowering interest rates for housing, using credit-allocation techniques where necessary... second, granting housing allowances, so that low- and moderate-income families are given the dignity of choosing where they want to live, rather than having that choice made for them by the government... third, achieving equal housing opportunity for the elderly of all races through effective enforcement of fair housing laws on the one hand, and, on the other by funding supportive services that will make such housing really work... fourth, implementing the housing and community development programs impounded by the Nixon Administration and frustrated by the recession from which we now appear to be recovering... and fifth, making a concerted attack on the redlining and other urban disinvestment policies which have laid waste whole sections of our major cities, including, I am sorry to say, portions of The Bronx.
In implementing this program to bring America’s great housing industry back once again to vigorous health, private investors and government agencies alike must be sensitive to the special needs of the elderly. To insure this sensitivity at all levels of decision making will require coordinated action and effective advocacy of the interests and concerns of older Americans.
Concern and action to make that concern meaningful must constitute the heart of a national strategy for the aged. How we provide for the elderly among us is a measure of who we are as a people and what we stand for. When we assure the elderly the dignity of choice, we affirm our own humanity, and we demonstrate our confidence in the American future.
The policies I have advocated to you today seek that goal. They will not be set in place and implemented in a day or a month, or in one year or four. But they show the direction in which I believe we should strive to advance. I hope that in time the leadership for a nationwide advance on behalf of the elderly -- indeed, on behalf of all Americans -- will come from Washington, specifically from the White House. The real test of political leadership in America, I am convinced, is not to command like a sovereign but to teach... and, through that teaching, to tap the enormous potential for positive, creative, community-serving action that lies in each of us -- men and women, black and white, young and old.
When such leadership is given to America, I am confident that the people will respond, and that their response will launch this nation into a new era, a new century of greatness. In that era, the aged will be freely given the opportunity to contribute to that greatness. They will not dream dreams by the fire -- along with the young, they too will see visions, and they will help to bring them to reality, for themselves and for us all.
